In recent years, orthopaedic subspecialty training has increased, and in particular, the number of fellowship-trained orthopaedic trauma surgeons (OTS) is rising in the United States.1 To match the increasing popularity of orthopaedic trauma, there have been an increasing number of fellowships and positions in recent years, from 58 in 2003 to 81 in 2011.2 This increase has engendered some concerns among new orthopaedic trauma graduates over the availability of trauma-only positions, and also over the ability of new OTS to gain experience in complex injuries in the setting of diluted case volume.2 Concurrently, the US population is increasing over time, which may lead to increases in traumatic orthopaedic injuries.3 It is not known whether the rate of increase in orthopaedic trauma injuries matches the number of OTS. The purpose of this study was to investigate recent trends in orthopaedic trauma and to assess whether the increased supply of OTS matches the demand for their skills.
To our knowledge, there are no comprehensive studies investigating specific supply and demand for fellowship-trained OTS in the recent decade. Some works have suggested that the supply of orthopaedic surgeons in general will fall short of the potential demand for orthopaedic services in coming years because of the aging population,4 although such projections are fraught with variability. In 1998, the RAND corporation projected an overall surplus of orthopaedic surgeons by 2010,5 which was not the case.6 In 2010, Fehring et al7 performed a supply and demand analysis in joint arthroplasty and reported a potential supply-side shortage by 2016 that could compromise patient access to care. Salberg et al4 also reported the potential for a concerning shortage of orthopaedic surgeons in general. Conversely, a study in 2014 reported that the population growth-adjusted incidence of unstable pelvic fractures has been relatively stable over time8; this, coupled with the rising number of fellowship-trained OTS, suggests that the opposite may be true for orthopaedic traumatology. Higher case volume per hospital and per surgeon is associated with fewer complications and improved patient outcomes; therefore, accurate demand estimates for OTS are important to promote optimal orthopaedic trauma training and patient care.9
In this study, we present a supply and demand analysis of the orthopaedic traumatology workforce. Given the growing concern for job availability and recent studies indicating a decline in open traumatology positions, we hypothesized that the supply of OTS has increased at a comparatively faster rate than the demand from 2002 to 2012. We suspect that this has led to a relative surplus of fellowship-trained OTS in recent years.
The exact number of practicing orthopaedic traumatologists, and also the demand for their services, is not feasible to quantify with complete accuracy. We therefore used surrogate estimates of supply and demand so that relative rates of change could be measured over time, and thus supply and demand could be estimated and compared. Data were obtained from the Orthopaedic Trauma Association (OTA), American Academy of Orthopaedic Surgeons (AAOS), and the National Trauma Data Bank (NTDB) provided by the American College of Surgeons (ACS).
The supply of OTS was estimated using OTA membership data (active, clinical, and associate) as a surrogate. These data were obtained from OTA directly. The number of OTA members was recorded for each year from 2002 to 2012, and the rate of change was calculated for each year. Additionally, the number of orthopaedic surgeons treating traumatic orthopaedic injuries as reported by the AAOS census was recorded for each year, and again the rate of change was calculated.10 It should be noted that the AAOS census response rate is not a complete reflection of all orthopaedic surgeons in practice; in 2012, 9025 (32.5%) of the 27,773 orthopaedic surgeons responded to the census survey. Thus, OTA and AAOS data may be useful for analysis of trends but are not exhaustive of the actual supply of OTS. Finally, the number of OTS working in NTDB reporting trauma centers was recorded, and the number of OTS per center was calculated for each year; again, this annual rate of change was calculated. Recognizing that OTA membership and AAOS data are not an absolute count of the number of OTS, this method was considered the most available surrogate for this analysis.
Accurately estimating the demand for fellowship-trained OTS represents a challenging aspect of this study. Board-certified orthopaedic surgeons in any subspecialty may treat many injuries such as femoral shaft fractures, intertrochanteric fractures, ankle fractures, forearm fractures, etc. In addition, complex periarticular injuries are often managed either by orthopaedic traumatologists or by subspecialists in the injured extremity (ie, a hand surgeon may manage a complex distal radius fracture, and a foot and ankle specialist may manage complex distal tibia fractures). In contrast, complex pelvic and acetabular fractures requiring operative fixation are almost exclusively managed by OTS with trauma fellowship training. Therefore, to most accurately estimate demand for OTS, pelvic and acetabular fractures were used as a surrogate. This estimate does not, therefore, account for trauma surgeons whose practice extends beyond pelvic and acetabular trauma, and certainly the need for traumatologists extends far beyond purely pelvic and acetabular injuries. Simply stated, we used only these injuries as a surrogate/estimate in an attempt to count injuries exclusively managed by fellowship-trained OTS.
The annual number of operative pelvic and acetabular fractures reported by ACS-verified trauma centers in the NTDB was recorded from 2002 to 2012, and the rate of change each year was then calculated. We used the NTDB Research Data Sets from 2002 to 2012 in an attempt to capture every case reported by ACS trauma centers; we did not use the National Sample Program data. Cases were included only when both ICD-9 diagnosis and procedure codes for pelvic and acetabular injuries were present to capture only operative injuries. This method is again an estimation, because there is no way to ensure that every case presenting to these centers was actually reported; there conceivably are “low-energy” cases that were not reported or captured in this analysis and would thus contribute to an underestimation of demand with this method. A primary problem with this method was the fact that the number of reporting centers increased each year, which naturally led to more operative pelvic and acetabular injuries being reported. To control for the rising number of reporting centers, demand was estimated by calculating the number of operative cases per reporting center over time. Thus, each year, the number of operative pelvic and acetabular injuries per NTDB center was recorded, and the annual rate of change for this value was calculated.
Supply and Demand Comparison
Because surrogates were used to estimate supply and demand and because the number of reporting ACS-verified trauma centers increased each year, a supply and demand analysis using raw numbers was not feasible. Therefore, annual rate of change in demand and supply was calculated and compared over time to estimate trends in the orthopaedic trauma workforce. These methods are not adequate to accurately report on the actual incidence of these injuries.
Overall supply and demand trends from 2002 to 2012 are presented in Table 1. The trend of OTA members increased each year, starting with 343 in 2002 and increasing to 861 in 2012. Increases were seen every year except in 2009, giving a mean annual increase of 9.8%. In addition, the mean number of total orthopaedic surgeons per NTDB center increased from 7.98 to 8.58, representing an average increase of 1.5% per year. The number of orthopaedic surgeons reporting to the AAOS census that they manage orthopaedic trauma increased each year beginning in 2007, with large increases of 55.9% and 35.8% in 2009 and 2010, respectively. Finally, over this period, there were an increasing number of OTA-certified trauma fellowship positions, and also an uptrending number of graduating fellows each year (Fig. 2).
In the years studied, overall reported operative pelvic and acetabular injuries increased by an average of 21% per year (Table 1). There were an increasing number of NTDB trauma centers reporting each year, beginning with 91 centers in 2002 and increasing to 805 centers in 2012. Thus, the number of operative cases per center was recorded. These data are also presented in Table 1. In 2002, the number of operative pelvic and acetabular injuries per center was 27.7; over time, this decreased to 19.03 cases per center in 2012, representing an average annual decrease of roughly 2% per year over this 10-year period. Figure 1 shows a graphical representation of the trends in annual increase in supply (OTA members) and the average annual decrease in demand for pelvic and acetabular surgeons. It should be noted that the number of level 2 and level 3 centers reporting increased more than the number of level 1 centers; thus, the number of cases per center is not specifically representative of any one center, in particular, but is an average of all reporting facilities.
The number of new fellowship-trained OTS has increased in recent years, which has been associated with a decreasing number of available positions for new graduates.1,2 This trend departs from orthopaedics, in general,4,11,12 and has generated concern among new orthopaedic trauma fellows both for the ability to secure a job in the field and also over the potential for case volume dilution and decreased operative experience. Indeed, it has been shown that outcomes improve and complications decline with greater hospital and surgeon case volume for specific procedures.7 These changes raise the question of whether the appropriate number of orthopaedic traumatologists is being trained each year to meet the demands of the population without diluting per-surgeon case volume and potentially compromising patient care through oversaturation. This study represents the first specific supply and demand analysis of the orthopaedic trauma workforce from 2002 to 2012 and is intended to explore the question of whether the supply of OTS met the demand and also to provide a potential framework for more in-depth analyses in the future. In this study, we estimated that from 2002 to 2012, the number of fellowship-trained OTS increased significantly, along with the number of orthopaedic surgeons per NTDB trauma center. Concurrently, the estimated number of annual operative pelvic and acetabular cases per NTDB center declined. These estimates suggest a trend toward an overall net loss of pelvic and acetabular cases per OTS over this 10-year period.
A few recent studies have highlighted a growing concern in the field of orthopaedic traumatology over the potential for case dilution and decreased job availability. Judd et al2 reviewed and tabulated the number of advertised orthopaedic trauma positions from 2003 to 2011 and showed a steady decline in the number of positions concurrent with a steady increase in the number of newly trained fellows. Cannada1 also highlights this concerning trend and discusses the potential need for the governing bodies in orthopaedic trauma to more closely scrutinize the number of fellows needed each year. The findings of this study may indicate a need for fewer orthopaedic trauma fellows in the immediate future and may also provide a framework for repeating this analysis to periodically address this question.
A primary concern with an increasing number of fellowship-trained OTS is the potential for dilution of case volume and surgeon experience. This study suggests that over the study period, the number of pelvic and acetabular fractures per reporting NTDB center trended downward. This may be the result of a growing number of OTS spreading out to take jobs and perform operations both at community hospitals and large referral centers, although this is speculation. If a reality, this phenomenon would have important implications for the quality of surgical care in complex pelvic and acetabular injuries. Studies in other subspecialties have shown that decreased case volume correlates with higher complications and worse patient outcomes compared with higher volume surgeons.9,13 Shervin et al9 performed a systematic review in which they reported that increased surgeon and hospital volume for total hip arthroplasty was associated with lower mortality and dislocation rates. Browne et al14 reported evidence to suggest that higher surgeon volume is associated with decreased mortality, morbidity, and length of stay after treatment of hip fractures. Singh et al15 showed that surgeon volume was significantly inversely correlated with length of stay, blood loss, and operative time in shoulder arthroplasty. These reports highlight the importance of surgeon volume to optimize patient outcomes that can likely be extrapolated to other areas of subspecialty care.
This study is not without limitation. Supply and demand analyses in general are inherently inexact, as the precise supply and demand for any good or service are not possible to track. In this case, supply was estimated using OTA membership, graduating trauma fellows, and AAOS census data as surrogates, which certainly could miscalculate the actual number of practicing traumatologists in the United States. Additionally, demand was estimated using pelvic and acetabular fractures as a surrogate, which also may not accurately represent the actual demand for OTS. Given the potential for underreporting, it is likely that the demand estimates used here could underestimate the true demand for trauma surgeons. In particular, this study did not factor in complex, periarticular fragility fractures; this may have also led to an underestimation of the true demand for OTS given the aging population. To be sure, the practice of orthopaedic trauma surgery extends well beyond purely pelvic and acetabular trauma. As such, this demand estimate cannot be used to comment on the need for OTS to manage injuries other than those of the pelvis and acetabulum. Notwithstanding, we selected only pelvic and acetabular injuries to be used as a surrogate to exclude the possibility of counting cases performed by other subspecialists. Furthermore, the NTDB may not capture many lower-energy or geriatric acetabular and pelvic fractures, even if these injuries are managed at level 1 centers. This limitation will likely contribute to further underestimation of the demand for pelvic/acetabular surgeons based on the methods used in this analysis.
The number of pelvic and acetabular injuries increased substantially over the study period; however, this was most likely due to increased reporting rather than a true increase in incidence. In fact, this study was not able to determine the actual incidence of these injuries with the methods used. To account for this, the number of cases per reporting center was calculated and used as the primary surrogate for demand. Although this would accurately control for the increasing number of reporting centers, the fact remains that this estimation technique could miss a more substantial increase in pelvic and acetabular injuries in the United States. This method also cannot account for changing surgical indications or for the possibility of more low-volume centers reporting and thus diluting the calculated number of cases per center. Finally, this study does not answer the question of whether declining case volume per surgeon does in fact correlate with worse outcomes in pelvic and acetabular surgery. Studies in other subspecialties and in hip fracture care have shown such an association.
Based on the surrogates used for this analysis, the trend in the number of OTS increased significantly from 2002 to 2012, as did the number of orthopaedic surgeons per NTDB trauma center. Conversely, estimates of the annual number of operative pelvic and acetabular cases per trauma center declined over the same period. These trends in combination suggest an overall net loss of annual operative pelvic and acetabular cases per surgeon over this 10-year period. In addition, the findings of this study introduce potential new areas for study that may improve on our ability to meet the orthopaedic needs of the changing population. The results of this study suggest that there may not be a need for increasing the number of surgeons trained in pelvic and acetabular surgery in the immediate future; however, these results cannot be extrapolated to evaluate the need for surgeons trained in managing other complex orthopaedic injuries. The findings presented here cannot and should not be used to direct policy or practice; instead, this exploratory study is intended to assess trends in the orthopaedic trauma workforce and provide a framework for discussion and potential future analyses.
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